States may hamper health exchanges

Uncertainty over the fate of health reform, centered on the Supreme Court case and the presidential election, has led some states to adopt a wait-and-see approach that may make it impossible for them to meet Health and Human Service’s timeline for building their own insurance exchanges.

With legislatures convening for their 2012 sessions, more states may adopt the same stance, jeopardizing their shot at exercising full control over their new insurance marketplaces when January 2014 arrives.

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States still on the fence are likely to decide in the next couple of weeks whether they will push forward on a state-based exchange this year or else yield at least partial control to the government, said Joy Wilson, health policy director for the National Conference of State Legislatures.

“We’ll have a much better idea of how the 50 states look in about two weeks,” Wilson said in a recent interview. “In this election year, my sense is they’re going to figure out whether they have the political support to go forward pretty soon and move on, one way or another.”

Especially in red states that hoped to pursue a conservative free-market-oriented exchange, that political support may be harder to come by now than it was just last fall, before hostility to health reform roared back to the fore in the Republican presidential primary.

“Even in states that want a private, free-market-driven system, there’s enough flexibility in the law and federal funds to design and build it,” said Mila Kofman, former insurance commissioner of Maine and now a health policy expert at Georgetown University. “But the whole discussion is so politicized, it’s become hard for people to even talk about what’s the right thing to do for the consumers in a state.”

Many conservative states that failed to pass or even consider exchange legislation in 2011 spent the fall studying exchange options ahead of the 2012 legislative sessions. But the political landscape has shifted again, dramatically in some states, with the GOP presidential campaign casting health reform back in a harsh light.

“Republican candidates for president, to an individual, all oppose the [Affordable Care Act],” Wilson said. “Many have suggested that moving forward makes it look like you’re supporting it, and that makes it difficult on the Republican elected officials.”

A Robert Wood Johnson Foundation report out Monday on state progress noted that the states that have the most to gain — potentially seeing the percentage of uninsured fall by half or more — tend to be doing the least on exchange implementation. The report found that 14 states and the District of Columbia have made significant legislative progress enacting an exchange, 21 states have drawn on federal grants to begin planning and 15 states have made little or no progress in the two years since health reform passed.